PhD candidate and chapter member Tawna Skousen gave an informative, rousing presentation at the May meeting of Humanists of Utah about how different laws and people define death and dying, pointing out interpretations and circumstances that make defining death not as simple as we may believe.

What is death?

Death is a term that refers to either the termination of life in a living system or the state of the organism after that event. The traditional definition of death is that the organism stops breathing and the heart stops beating.

Biologically, death can occur to wholes, to parts of wholes, or to both. Individual cells and organs can die yet the organism as a whole can continue to live. Or an organism can die yet its cells and organs continue to live; transplantation is possible because of this phenomenon. Irreversibility is part of the traditional definition where the organism cannot be brought back to life with an irreversible loss of vital fluids.

Irreversible also is cessation of all brain functions where even the brain stem stops functioning but is this death? The permanent loss of consciousness is part of irreversible coma although the heart is still beating and breathing is still occurring. Is this death? Some people believe that life stops when a person loses ability to think [e.g. make decisions, has sense of past and future, is rational and logical, etc.], feel emotions, and interact socially.

Identifying death

Identifying death is important because this a) Allows correct timing on the death certificate. b) Those responsible will act only after the person is truly deceased. c) Allows organ transplantation.

Definitions of death

Differing definitions of death: Prior to ventilators, CPR, and other technological means, death meant cardiovascular failure and breathing cessation. Since the 1960s, death shifted from an event to a process. The law, however, still approaches death as an event rather than a process, and as a matter of status rather than a medical condition.

Since 1968, differing perspectives on defining death began with "brain death," the entire cessation of cerebral function or the whole brain while the person is still breathing and heart still beating. Few patients meet these criteria, however. The majority of cases are far more complex involving severe neurologic damage. In the 1970s, various statutes were proposed and adopted with brain-based criteria for defining death.

Most of the time, it's pretty easy for doctors to tell when someone is dead; the person's breathing and heartbeat stops and can't be revived. But this changed when Congress passed the Uniform Determination of Death Act in 1981, stating that an individual, who has sustained either a) irreversible cessation of circulatory and respiratory functions or b) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.

With this act, the overwhelming majority of organ donors have been declared dead by a very different standard: Machines keep their hearts and lungs pumping, but doctors determine that their brain and brain stem have irreversibly stopped functioning. Now, some ethicists and doctors are beginning to question the validity of the brain death diagnosis. At a minimum, they say, many brain-dead people still have some brain activity, making the declaration of death less clear.

Vegetative States

Persistent Vegetative State and Permanent Vegetative State: These vegetative states are not considered death although the courts may authorize withdrawal of artificial nutrition and hydration after six months of no improvement.

It is considered "persistent" after one month in a vegetative state, considered "permanent" after three months if caused by non-traumatic events such as oxygen deprivation to the brain, and considered "permanent" after one year if caused by traumatic injuries such as a blow to the head. Guidelines for children are different.

Changing Laws

Instead of defined as a moment, death has evolved into also a process. Patients now have the right to refuse life-sustaining treatment, defined as medical procedures or interventions when used by one with a terminal condition serves only to prolong the dying process; this right excludes palliative care. "Terminal condition" is defined as an incurable or irreversible condition for which continuing medical treatment would not improve health but only prolong the dying process. Regardless of treatment, death would be imminent within reasonable medical judgment.

Here the crucial questions are when did the dying process begin, and when is death imminent? Persistent and permanent vegetative state patients are a predicament because they are not terminally ill nor are they brain dead.

In addition is the continuous battle between the "sanctity of life" [all life is equal] versus "quality of life." Technology creates the imperative that if it can be done, we will do it whereas ethics asks if we should do it and who should decide the best course.

Widely covered by the media, the most recent ethics case has been of Terri Schiavo. Skousen also cited the cases of Karen Ann Quinlan, Nancy Beth Cruzon, Anthony Bland, Trisha Marshall, Terry Wallis, and Marion Ploch.

The Future

Currently the courts are the final arbiters although in the years to come will be continuous debate and discussion involving the patient's family, the patient's wishes, social mores, religious traditions, and the medical profession.

The definition and determination of death according to Utah code is:

1. An individual who has sustained either:
Irreversible cessation of circulatory and respiratory functions;
• Irreversible cessation of all functions of the entire brain, including the brain stem; is dead.
2. A determination of death must be made in accordance with accepted medical standards.

For more information about Utah State Laws concerning death, click here

--Sarah Smith